HRSA Health Center Workforce Survey: Pilot Survey

Questionnaire and Data Collection Testing, Evaluation, and Research for the Health Resources and Services Administration (HRSA)

Documents and Forms

Document Name Document Type
Form 2 HRSA Health Center Workforce Survey: Pilot Survey Form and Instruction
2 HRSA Survey Draft HRSA Survey Draft V6.1.docx Form and Instruction
2 HRSA Survey Draft HRSA Survey Draft V6.1.docx Form and Instruction
1 Informed Consent Pilot Survey Informed Consent_07192021_CLEAN.docx Form
1 Informed Consent Pilot Survey Informed Consent_07192021_CLEAN.docx Form
Pilot Survey Supporting Statement A 07192021_CLEAN.docx Supporting Statement A IC Document
Pilot Survey Supporting Statement A 07192021_CLEAN.docx Supporting Statement A IC Document
Pilot Survey Supporting Statement B 07192021_CLEAN.docx Supporting Statement B IC Document
Pilot Survey Supporting Statement B 07192021_CLEAN.docx Supporting Statement B IC Document
Pilot Survey Invitation Email from Health Center 07192021_CLEAN.docx Pilot Survey Invitation Email from Health Center IC Document
Pilot Survey Invitation Email from Health Center 07192021_CLEAN.docx Pilot Survey Invitation Email from Health Center IC Document
Pilot Survey Invitation Email from JSI 07192021.docx Pilot Survey Invitation Email from JSI IC Document
Pilot Survey Invitation Email from JSI 07192021.docx Pilot Survey Invitation Email from JSI IC Document
Pilot Survey Invite System Form.docx Pilot Survey Invite System Form IC Document
Pilot Survey Invite System Form.docx Pilot Survey Invite System Form IC Document

Information Collection (IC) Details

IC Title:	HRSA Health Center Workforce Survey: Pilot Survey	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	2	HRSA Survey Draft	HRSA Survey Draft V6.1.docx		Yes	Yes	Fillable Fileable
Form	1	Informed Consent	Pilot Survey Informed Consent_07192021_CLEAN.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 400	Number of Respondents for Small Entity: 400

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	400	400
Annual IC Time Burden (Hours)	300	300
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement A	Pilot Survey Supporting Statement A 07192021_CLEAN.docx	06/29/2023
Supporting Statement B	Pilot Survey Supporting Statement B 07192021_CLEAN.docx	06/29/2023
Pilot Survey Invitation Email from Health Center	Pilot Survey Invitation Email from Health Center 07192021_CLEAN.docx	06/29/2023
Pilot Survey Invitation Email from JSI	Pilot Survey Invitation Email from JSI 07192021.docx	06/29/2023
Pilot Survey Invite System Form	Pilot Survey Invite System Form.docx	06/29/2023

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.